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TUESDAY, Nov. 13, 2012 (HealthDay
News) — Cigarette packs featuring images of cadavers,
a field of weathered tombstones or yellow-toothed, cancer-riddled mouths may
indeed convince smokers to quit, a new study suggests, and those kinds of
pictures may have a particularly strong impact on less-educated smokers who are
less informed about health.

Researchers from the University of South Carolina wanted to examine
how cigarette packages featuring pictures related to the health fallout of
smoking influenced adult smokers compared to words-only warnings. They
recruited a less-educated smoking population because other studies show people
in lower socioeconomic groups with lower levels of education are among the
heaviest smokers with the highest tobacco-related disease rates.

While the issue is being wrangled over legally, the researchers said
they wanted to explore visual-warning use further, "to inform future
warning-label policy development and implementation," they wrote in their
study, which is scheduled for publication in the December issue of the
American Journal of Preventive Medicine.

"Research on cigarette warnings in the United States and other
countries has repeatedly shown that pictures work better than text," said
lead investigator Dr. James Thrasher, an associate professor in the department
of health promotion, education and behavior at the University of South Carolina
in Columbia. "Our research supports this finding while also showing what
tobacco researchers have assumed for a while — that warnings with
pictures work particularly well among smokers with low levels of
literacy."

The scientists recruited nearly 1,000 adult smokers for the study from
public places such as grocery stores, sporting events and flea markets across
South Carolina. They asked them questions about their education, salary levels,
race and smoking habits. All of the participants had to have smoked at least
100 cigarettes during their lifetime and had to currently be daily
smokers.

To assess their health literacy, the researchers asked each smoker to
interpret a nutrition label. The participants were randomly assigned to one of
two groups.

The control group of 207 male and female smokers, aged 18 and up, were
shown four text-only warnings currently used on cigarette packs, which warn of
lung cancer, pregnancy complications and other medical problems.

The other 774 individuals, also a mix of men and women over 18 who
smoked regularly, were shown nine different cigarette packs that carried
warning text and pictures showing the consequences
of smoking. While some visuals were very graphic —
including a close-up of a gray and scarred cadaver chest — other
pictures featured a distraught person or included more abstract visual images
warning of cancer, heart disease and stroke.

Both groups rated the messages according to credibility, personal
relevance and effectiveness. Smokers' ratings of personal relevance and
effectiveness were higher for the warnings with pictures compared to the
warnings with just words. Smokers with low health literacy rated the warning
labels with pictures as more credible than text-only messages, the authors
reported.

"I'm not that surprised with what it finally showed," said
Dr. Aditi Satti, director of the Smoking Cessation Program and an assistant
professor of medicine at Temple University Health System, in Philadelphia.
Satti was not involved in the research.

"The study did target patients who might not listen to other types
of messages — a lower-income, less educated population," she
said. "A picture is probably worth a thousand words in this type of
patient."

Whether an image on a cigarette package is going to correlate to
increasing quit rates is unclear yet, added Satti, but she said including
pictures on warning labels is a good first step.

"It gets people at least thinking about what the consequences of
smoking cigarettes are. It gets them in the contemplation state," Satti
said. She also pointed out that people live in a more visual world now, with
quick images on television, in games and in movies, so this type of study in
younger adolescent smokers is also worth exploring.

According to the U.S. Centers for Disease Control and Prevention, 21 percent
of the adult population smokes. It's the leading cause of early, preventable
death in the United States, and linked to 443,000 deaths a year and close to
$200 billion in medical expenses and lost productivity.

"The U.S. should put prominent, graphic warnings on cigarette
packages," Thrasher said. "Smoking is highest among people with the
least education in the U.S., and the government needs to do something about
it."

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